Senate Passes Budget Deal; No SGR Fix Included

WASHINGTON -- The Senate has passed the $1.1. trillion budget deal, clearing the way for President Obama to sign a measure that has disappointed many physician groups.

The budget bill, which was passed by the House on Thursday, passed the Senate Saturday night by a vote of 56-40. The bill lacks any fix to the widely hated sustainable growth rate (SGR) formula for physician reimbursement under Medicare. Also missing in action: an extension of the current pay bump for primary care physicians who see Medicaid patients.

Anders Gilberg, senior vice president for government affairs at the Medical Group Management Association's (MGMA) Washington office, said Friday he was disappointed about the lack of an SGR fix, especially since there was already generally agreed-upon legislation to fix it.

"The medical community has been pushing hard to have the SGR addressed in a lame duck session because this is the only time the legislation has advanced in both houses in all parties of jurisdiction," he told MedPage Today in a phone interview. "The policy was basically totally agreed on; the big impediment was paying for it ... Now we've totally hit the 'Reset' button on this issue."

David Fleming, MD, president of the American College of Physicians, agreed, noting that the cost of repealing the SGR -- estimated by the Congressional Budget Office (CBO) at around $140 billion -- is the lowest it's been in quite some time. As a result, "it would have been a much less painful process in terms of how we balance that part of budget," he said in a phone interview Friday. "Everybody realized that, and they did recognize the fact that this isn't going to be nearly as bad as we thought it might be based on the new projections."

"I hope that opportunity sustains itself," continued Fleming, who is chair of the department of medicine at the University of Missouri in Columbia. "There is a great opportunity to act and do it in a fiscally responsible way."

Congress really faces two choices, he added. "Either they are going to have to be ... getting rid of the SGR and balancing that part of the expense, or there is going to be a massive cut in reimbursement for physicians, and that's going to ultimately trickle down to patients and there is going to be less access. It hurts either way, and at some point, a very bitter pill is going to have to be swallowed. We can't keep doing this indefinitely."

Gilberg noted that "patches" to the SGR to avert payment cuts -- and if there is another patch passed early next year, it would be the 18th one -- don't come free. The cost of continuous patching for 10 years -- from 2014 to 2024 -- runs about $16 billion, according to the CBO.

Fleming also expressed disappointment about the House bill's failure to increase the primary care pay bump for Medicaid physicians to bring their rates into parity with those of Medicare. "We did a member survey and found that 40% would cut back or stop seeing Medicaid patients altogether if parity was not sustained," he said. "If appropriate funding is not provided for Medicaid, certainly if major cuts occur in Medicaid, then many patients are at risk."

Gilberg said that MGMA also is "very concerned" about the lack of an extension of the Medicaid pay bump. He cited an analysis by the Kaiser Family Foundation showing that 15 states planned to make sure the pay bump would be maintained, at least in part, while 24 did not and about a dozen were undecided.

"So in every state other than those 15, there could be significant cuts, with fees reduced by 30% to 50%," he said. "We'd like to see that issue addressed, but addressed in the context of SGR because ... you have to address the fundamental issues as well as the inequity between the two."

One other item on the ACP's radar screen is the fate of the Affordable Care Act's 10% pay increase for primary care providers in the Medicare program, Fleming said. "We have one more year with that, and we hope that will get extended as well. We don't know what the impact would be if we lost it, but my guess is it would have a similar impact on the attitudes of healthcare providers" as a failure to renew the Medicaid pay increase.

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